GW1-2022-07190_Well Construction - GW1_20220801

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 214243
1.W ELL CONTRACTOR: K HTH 30
KEITH PRESNELL f. DISINFECTION:Type Amount
�aa� y ) g. WATER ZONES(depth):
Well UttVVtY(I Yi(5U4l1N LL &PUMP CO., INC. From 130 TO Ijl From 165 TOlt36
From To From To
Well Contractor Company Name
P.O.BOX 30$ From To From To
STREET ADDRESS 6.CASING: Thickness/
$GONE NC 286(Y7 0 Depth 80 D�iafiter Tge ht Vaatterial
From To Ft.
City or Town State Zip Code
= 264-2651 From To Ft.
( )- From To Ft,
Area code-Phone number
7.GROUT: Depth tg�`ia�l�� Meth
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2.WELL INFORMATION: 0 20 $ 86 a vlty�.ova
- - ---— —From - To -- Ft; -- —
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 361525 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap licable Box): Residential Water Supply] From To Ft. in. in.
'pill 1/2022
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BANNER ELK waag Depth Size Material
CITY: COUNTY From To Ft. en
157 7 DEVILS RD OFF 7 DEVILS RD OFF HWY 105 From _To ,Ft.
1 ««(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft. AUG
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG Intofmation Pm% Unit
❑Slope ❑Valley X7 Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 70 DIRT
36.145794 May in degrees, 70 130 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE - M25 in a decimal format 130 131 VOID
Latitude/longitude source: 6 GPS ❑Topographic map 131 140 QUARTZ
(location of well must be shown on a USGS topo map and 140 165 GRANITE
attached to this form if not using GPS) 165 166 VOID
4.WELL OWNER 166 205 GRANITE
OWNER'S NAME TOWN OF SEVEN DEVILS
STREET ADDRES
BANNER ELK. NC 28604
City or Town State Zip Code
(( = 1 963-6193
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 5 GPM 136- 131 i25 GRA 165- 166
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS]
c. WATER LEVEL Below Top of Casing: 60 FT. 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T
WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface` AV
'Top of casing terminated at/or below land surface may require V -9- r p?p
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL ONT DATE
e. YIELD(gpm): 30 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn:Information'Mgt., Form GW-1a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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